Treatment Option Overview for Prostate Cancer-Summery Local treatment modalities are associated with prolonged disease-free survival for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors. Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation. Metastatic prostate cancer is currently not curable. Treatment options for each stage of prostate cancer are presented in Table 9. Table 9. Treatment Options by Stage for Prostate Cancer Stage (TNM Staging Criteria) Standard Treatment Options TURP = transurethral resection of the prostate. Stage I Prostate Cancer Watchful waiting or active surveillance Radical prostatectomy External-beam radiation therapy (EBRT) Interstitial implantation of radioisotopes Stage II Prostate Cancer Watchful waiting or active surveillance Radical prostatectomy External-beam radiation therapy (EBRT) with or without hormonal therapy Interstitial implantation of radioisotopes Stage III Prostate Cancer External-beam radiation therapy (EBRT) with or without hormonal therapy Hormonal manipulations (orchiectomy or luteinizing hormone-releasing hormone [LH-RH] agonist) Radical prostatectomy with or without EBRT Watchful waiting or active surveillance Stage IV Prostate Cancer Hormonal manipulations Bisphosphonates External-beam radiation therapy (EBRT) with or without hormonal therapy Palliative radiation therapy Palliative surgery with transurethral resection of the prostate (TURP) Watchful waiting or active surveillance Recurrent Prostate Cancer Chemotherapy for hormonal management of prostate cancer Immunotherapy Watchful Waiting or Active Surveillance Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment.[1,2] Watch and wait, observation, expectant management, and active surveillance are terms indicating a strategy that does not employ immediatetherapy with curative intent. Watchful waiting and active surveillance are the most commonly used terms, and the literature does not always clearly distinguish them, making the interpretation of results difficult. The general concept of watchful waiting is patient follow-up with the application of palliative care as needed to alleviate symptoms of tumor progression. There is no planned attempt at curative therapy at any point in follow-up. For example, TURP or hormonal therapy may be used to alleviate tumor-related urethral obstruction should there be local tumor growth; hormonal therapy or bone radiation might be used to alleviate pain from metastases. Radical prostatectomy has been compared with watchful waiting or active surveillance in men with early-stage disease (i.e., clinical stages T1b, T1c, or T2).[3] (Refer to the Radical Prostatectomy section in the Treatment Option Overview for Prostate Cancer section of this summary.) In contrast, the strategy behind active surveillance is to defer therapy for clinically localized disease but regularly follow the patient and initiate local therapy with curative intent if there are any signs of local tumor progression.[4-6] The idea is to avoid the morbidity of therapy in men who have indolent or nonprogressive disease but preserve the ability to cure them should the tumor progress. Active surveillance usually involves: • Regular patient visits. • Digital rectal examinations. • Prostate-specific antigen (PSA) testing. • Transrectal ultrasound. • Transrectal needle biopsies. Patient selection, testing intervals, and specific tests, as well as criteria for intervention, are arbitrary and not established in controlled trials. In the United States, as in other settings with widespread PSA screening, the results of conservative management of localized prostate cancer are particularly favorable. Many men with screen-detected prostate cancer are candidates for active surveillance, with definitive therapy reserved for signs of tumor progression. Evidence (watchful waiting or active surveillance): 1. A population-based study with 15 years of follow-up (mean observation time of 12.5 years) has shown excellent survival without any treatment in patients with well-differentiated tumors or moderately well-differentiated tumors clinically confined to the prostate, irrespective of age.[7] • Tumor was not detected in any of these men by PSA screening, since PSA was not available at the time. • The patient cohort was followed for a mean of 21 years after initial diagnosis.[8] The risk of prostate cancer progression and prostate cancer death persisted throughout the follow-up period. • By the end of follow-up, 91% of the cohort had died; 16% had died of prostate cancer. 2. A second, smaller population-based study of 94 patients with clinically localized prostate cancer managed by a watch-and-wait strategy had very similar results at 4 to 9 years of follow-up.[9] 3. In a selected series of 50 Jewett stage C patients, 48 of whom had well-differentiated tumors or moderately well-differentiated tumors, the prostate cancer-specific survival rate at 5 years was 88% and, at 9 years, the rate was 70%.[10] 4. In a population-based Surveillance, Epidemiology and End Results (SEER) Medicare-linked database, 14,516 men with localized prostate cancer (T1 or T2 cancer) diagnosed from 1992 to 2002 were followed on conservative management (no surgery or radiation for at least 6 months) for a median of 8.3 years. The median age at diagnosis was 78 years.[11][Levels of evidence: 3iA, 3iB] • At 10 years, the prostate cancer-specific mortality rates were 8.3% for men with well-differentiated tumors, 9.1% for men with moderately well-differentiated tumors, and 25.6% for men with poorly differentiated tumors. • Corresponding risks of dying of other causes were 59.8%, 57.2%, and 56.6%, respectively. 5. Another population-based observational study of men with clinically localized prostate cancer diagnosed in the PSA-screening era has also been reported, with a median follow-up of 8.2 years.[12] A nationwide Swedish cohort of 6,849 men aged 70 years or younger with T1 or T2 prostate cancer, Gleason scores of 7 or lower, and serum PSA levels of lower than 20 ng/ml was followed after an initial strategy of surveillance (n = 2,021), radical prostatectomy (n = 3,399), or radiation therapy (n = 1,429).[12][Levels of evidence: 3iA, 3iB] • The cumulative risk of prostate cancer-specific death at 10 years was 3.6% in the initial surveillance group and 2.7% in the curative intent groups (i.e., 2.4% in the prostatectomy group and 3.3% in the radiation therapy group). • The 10-year risk of dying from causes other than prostate cancer was 19.2% in the surveillance group versus 10.2% in the curative intent group, showing evidence of selection of patients who were not as healthy for surveillance on average. • Tumor pathologic characteristics of 222 men in that cohort who followed an initial strategy of surveillance but underwent deferred prostatectomy at a median of 19.2 months (10th–90thpercentile, 9.2–45.5 months) were compared with those who underwent immediate prostatectomy.[13] There were no differences between the groups in extraprostatic extension or tumor margin positivity. Although the Gleason scores at radical prostatectomy were higher in the surveillance group than in the immediate prostatectomy group, this occurred concurrently with a national training effort in prostate tumor pathology evaluation that led to the upgrading of tumor specimens. Therefore, the investigators concluded that the delay in prostatectomy in the surveillance group artifactually led to the assignment of higher tumor grades. 6. A retrospective analysis of outcomes of men with prostate cancer demonstrated a 10-year disease-specific survival rate of 94% for expectant management for Gleason score 2 to 4 tumors and 75% for Gleason score 5 to 7 tumors;[14] this is similar to a previous study using the SEER database with survival rates of 93% and 77%, respectively.[15] 7. In a retrospective analysis from the European Randomized Study of Screening for Prostate Cancer (ERSPC), 616 men (mean age of 66.3 years) diagnosed with prostate cancer in the screening arm met criteria for active surveillance that included PSA (≤10 ng/ml). PSA density (
Posted on: Fri, 04 Oct 2013 15:04:33 +0000
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